The ACE THE ACEM BOOTCAMP covered the key assessment systems for low and intermediate chest pain in the ED
WE reviewed the MJA 2016 ACS guidelines and looked at the
TIMI VS. EDACS VS HEART VS GRACE
scoring in ED
and looked at current pathways for accelerated chest pain pathways.
Key knowledge for the exam and on floor !!!
Another tough discriminating ECG for the Fellowship exam. The ACE THE ACEM BOOTCAMP covered atrial infarctions in the ED with the Lew Criteria as key to diagnosis:
PTa elevation > 0.5 mm in II, III OR AVF ( right side) or V4,5 ( left atrial)
With reciprocal PTa depression in precordial leads.
Also note the increased mortality associated with atrial rupture !!!
The ACE the ACEM BOOTCAMP covered it’s first cardiology session towards the May 2020 exam. D1 lesions are tricky to diagnose - STEMI in AVL and V2 with depression in III AND AVF. Look out for this tricky ecg in the exam and also on floor !
ACE the ACEM May 2020 webinar introduction - physiologically difficult airways - the HHAARRMMS mnemonic.
Airway assessment and management
We started the new webinar series in prep for May 2020 with some key structured thoughts on airway
The anatomically difficult airway
MOAN - bvm ppv possible?
RODS - LMA / extraglottic device possible ?
LEMON- Laryngoscopy possible?
SMART - Cricothyroidotomy possible ?
The PHYSIOLOGICALLY DIFFICULT AIRWAY
HOW WOULD YOU IPTOMISE YOUR RSI IF THE ABOVE WERE PRESENT ?
Have your devices ready to roll:
Standard : BVM BOUGIE CMAC ETT LMA
INTUBATING LMA / stylet
Fiber optic intubator
Know the following algorithms:
‘AWAKE’ oral intubation
Trauma Webinar 1 - permissive hypotension; trauma system triage based on physiology, anatomy, special populations and mechanism.
We covered general topics and chest trauma specifically across 2 webinars.
We looked at the
Physiological, Anatomical, Special patient populations and Mechanistic parameters that determine whether patient go to a trauma centre. Different jurisdictions have slightly different rules but based on the above categories.
Popular topic for discussion. Essentially not much evidence for its use.
aiming for cerebral perfusion while maintaining the blood clot while arranging definitive care through a surgeon.
Not for brain injury / children
see entries in LIFL
There is no high level evidence to support this approach
Delayed fluid resuscitation/controlled hypotension — Questions remain whether reversal of hypovolemia or control of hemorrhage should take priority in trauma resuscitation.
A growing number of researchers describe aggressive fluid administration as ineffective and potentially harmful and suggest that
limited volume replacement that maintains minimally adequate organ perfusion may improve outcomes
This strategy has been referred to as delayed fluid resuscitation, controlled hypotension, permissive hypotension, hypotensive resuscitation, or controlled resuscitation,
targets early fluid resuscitation only to a SBP of greater than 70 mmHg.
Controlled hypotension may be beneficial in patients with hemorrhagic shock due to torso injuries from gunshot or stab wounds.
may be detrimental to blunt trauma patients with brain injury, as hypotension reduces cerebral perfusion and increases mortality
The rationale for improved outcomes with delayed fluid resuscitation is that aggressive fluid administration might, via
augmentation of blood pressure,
dilution of clotting factors, and
production of hypothermia,
disrupt thrombus formation and enhance bleeding
In one widely cited prospective study of 598 patients with penetrating chest injuries treated at a major trauma center, delayed fluid resuscitation until operative intervention to control bleeding was associated with a statistically significant improvement in patient survival (70 versus 62 percent in those given immediate fluid repletion)
subjects were primarily young and healthy, and the mean time from injury to operation was two hours, results that are not attainable in most circumstances.
In a preliminary analysis of a trial conducted at another major trauma center, 90 young adults with penetrating (n = 84) or blunt (n = 6) trauma resulting in at least one SBP reading below 90 mmHg, and hemorrhage requiring immediate laparotomy or thoracotomy, were randomly assigned upon arrival to the operating theater to resuscitation using a low-goal mean arterial pressure of 50 mmHg (LMAP group) or a high-goal mean arterial pressure of 65 mmHg (HMAP)
Among the patients excluded were those with traumatic brain injury.
Anesthesiologists did not intervene to lower the blood pressure of patients in the LMAP group whose MAP exceeded 50 mmHg. Patients in the LMAP group had lower postoperative mortality (6 versus 10 deaths), received fewer blood products (1594 versus 2898 mL), and did not develop coagulopathy or multiple organ failure (MOF), compared with seven cases of coagulopathy and two cases of MOF in the HMAP group.
However, there was no significant difference between the groups in overall mortality at 30 days.
Other results favoring controlled hypotension or controlled resuscitation for both penetrating and blunt trauma patients include European guidelines published in 2013 recommending a target SBP of 80 to 90 mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury
Another randomized trial conducted by The Resuscitation Outcomes Consortium (ROC) published in 2015 concluded that controlled resuscitation (defined as SBP >70 mmHg) is achievable in out-of-hospital and hospital settings and may offer an early survival advantage in blunt trauma
The results of these studies notwithstanding, adoption of the strategy of delayed fluid resuscitation or controlled hypotension into clinical practice must be undertaken cautiously
Factors that should be considered when determining whether this strategy is appropriate include
the patient's mental status and
likelihood of intracranial injury,
likelihood of spinal cord injury (SCI),
underlying illness such as chronic hypertension and
proximity to a trauma center.
Further research to determine the appropriateness and effectiveness of this approach is needed
Based on current data, limiting fluid resuscitation to 1 L or less and moving directly to blood products appears to be the best strategy.
Nexus vs Canadian c spine rules vs pem approach
Nexus is 5 criteria - Neurology, evidence of intoxicating, eXtremity distraction, unconscious, spinal tender
nexus is less sensitive - 90% while CCSR is 95-99% sensitive - ccsr results in less imaging
Need to have an expert approach to children c spine imaging
essentially a combo of Nexus and ccsr can be used with high threshold to imaging because in the absence of multi trauma, nai or unconsciousness / mvc - the incidence of injury is extremely low.
plain film actually leads to increased CT usage because many false positives in the pediatric spine film.
generally observation with analgesia
mri first line test with orthodox consult or limited ct cspine of area of concern
Viral meningitis usually does not cause somnolence; Bacterial meningitis usually progresses to confusion; encephalitis usually results in bizarre behaviour.
Difficult meningitis scenarios were reviewed. The best resource to read is Harrisons textbook of internal medicine.
Acute meningitis presentations - bacterial, viral and encephalitis vs
subacute presentations of bacterial brain abscess
Viral meningitis does not cause somnolence / drowsiness
Bacterial meningitis progresses to confusion
Encephalitis often presents with bizarre behaviour
Meningism, kernigs and neck stiffness are late signs and only present in <20% of adults and fewer children. mortality once meningism is present is 20-30% -- so don't use this to rule out meningitis!!!
Best resource for difficult types of meningitis eg TB, cryptococcal, syphillis is Nelsons textbook of paediarics or UTD.
see tables attached below
This is a massive topic in the EM syllabus. Detailed discussions were completed on :
Stroke syndromes - aca amca pca etc, lateral medullary syndrome - anatomy, ct findings, mri and correlation with clinical features
A good resource for this is Harrisons
Acute thrombolysis guidelines and current literature =such as acem policy on acute stroke, - detailed knowledge of the stroke protocol is needed - suggested reading includes UpToDate or stroke review articles
knowledge of HIHSS scoring and modified ranking evaluation is important
Medical management and hypertensive management in stroke situations.
A review of the topic of headache was completed in the webinar focussing on:
Classification - Primary (migraine, cluster etc) vs Secondary headache (infection, ich, mass, trauma, etc)
Key dangerous causes to exclude eg sah, ich, mass, infection, trauma, face, ear, throat, Giant cell arteritis, teeth, sinus.
International headache classification and definitions
evidence based pharmacology for migraine management incl details of which drugs in which types of patients - detail from UTD required.
This webinar introduced the topic of neurology and started with an exam favourite - seizures.
The approach to seizure classification - organic (trauma, infection, metabolic, toxin, ins lesion) vs idiopathic epilepsy (and its types eg generalised, myoclonic etc) and definitions around provoked and unprovoked seizures.
A consultant approach to managing:
Airway and critical threats
diagnosing the cause of the seizure
done in a seemless and simultaneous fashion.
A detailed approach to RSI and ongoing sedation in the SE patient
An appreciation of the important pivotal clinical features to look for followed by investigation approach.
The topics of first seizure approach vs second seizure is important.
A detailed review of status epileptics and drug knowledge is important and should be reviewed in Up To Date.
The table in Rosens on special seizure situations eg hyponatraemia / eclampsia and departures from standard therapy.
This was a jam-packed session on surgical conditions common to the exam (and the floor!!)
We reviewed a good approach to abdominal plain film and CT abdomen referencing Rabi et al and CT radiology teaching atlas.
useful for obstruction, perforation, volvulus patterns, toxic megacolon
1.assess general gas pattern - caecum, tvs, descending, air in rectum, small bowel pattern in middle.
2.free air pattern? RUQ air? gas around organs? air on both sides of bowel wall ? ligament teres or falciform lig signs?
3. obstruction patterns- fluid levels, large bowel or small dilated , ileocecal valve competent? cecal or sigmoid volvulus
CT / CTA
abd wall - free air beneath
liver and liver kidney area (hepatorenal space)
spleen and kidney (splenorenal space)
gallbladder - thickening
cecum - tvs - descending - sigmoid colon - rectum - in axial profile
bowel wall thickening - infection, inflammatory, ischemia, cancer, ibs
gas in gallbladder
gas in portsplenic circ
pneumatosis intestinalis (air in bowel wall)
sma ischemia on cta
bush on trauma cta - bleeding
Using the above summary tool for assessment we reviewed films ct and uss on the following topics.
The 'analysis' part of the question was the image analysis and the knowledge component was review of causes, classification, symptoms etc using the guide above
we did a rapid 1 min of sections using
risk factors, 5 points on clinical review, severity assessmnt, complications
checking for all of these on the scan
Gallstones - colic vs acute cholecystitis vs cholangitis
Tokyo guidelines 2013
Pancreatitis - focussed on severity scoring for prognosis and disposition
- BISAP vs ransons vs CT severity index vs apache vs sirs score
BISAP = renal f + SIRS + age + effusion
BUN > 25 mg/dL (8.9 mmol/L)
Abnormal mental status with a Glasgow coma score < 15
Evidence of SIRS
> 60 years old
Bowel wall thickening DD:
infection - clostridium, shigella, campylobacter, e coli (has related toxin producing), yersinia
inflammatory - UC / chrohns / vasculitis / sle
neoplasm - primary adenocarcinoma / mets / sec to nodes form lymphoma
ibs - low on the list